Multiple drug overdose in a kidney transplant patient

Development of depression in patients with organ transplants is accompanied by an increased incidence of suicide attempts. A 60-year-old man with chronic polycystic renal disease underwent a kidney transplant 2 years previously. Six months prior to admission, the patient had been medicated for depression. This course was complicated by noncompliance and worsening family problems. One morning, the patient was found unconscious, along with a suicide note and empty bottles of cyclosporine (CsA), imipramine (IP), meticorten, azathioprine, oxazepam, alprazolam, and fluoxetin, approximately 24 h after the presumed intake of these agents. Initial plasma IP level was 2260 ng/ml, whole blood total cyclosporine (T-CsA) concentration was 1,800 ng/ml and that of specific cyclosporine (Sp-CsA), 714 ng/ml. Urine toxic screening was positive also for benzodiazepines metabolites. IP and CsA blood levels were measured daily. Five days after overdose, the IP concentration was 232 ng/ml, that of T-CsA 401 ng/ml, and that of Sp-CsA 96 ng/ml. Compared to subjects on therapeutic doses, a significant prolongation of the half-life, t 1/2, was observed for both IP (t1/2, 43.4 h) and Sp-CsA (t1/2, 70.1 h). In the present case, prolonged elevated IP plasma levels were not associated with cardiovascular complications. On the 5th hospital day, after the patient had apparently recovered from the intoxication, he jumped from the 8th floor to his death.